Which approach to learning represents the view that people learn from the consequences of their actions?

Social cognitive theory

One of the most widely used and robust health behavior change theories, SCT emerged from social learning theory, which identified that people learn from their own experiences and by observing the experiences of others.37 There are three major constructs in SCT that interact to influence behavior: personal factors (age, cognitions, previous experience with the behavior, etc.), environmental factors (access to resources, safety, support from family/friends, etc.), and aspects of the behavior itself (vigor of the behavior, outcomes achieved as a result of practicing the behavior, competence with the behavior, etc.). Successful efforts to change behavior depend on identification of the positive supports and the detractors in each of the three constructs. For example, if a therapist is managing the physical or occupational therapy services of a patient who has multiple sclerosis and this patient is motivated to be physically active yet does not have a safe place to walk or be physically active near home, the patient will likely not be able to consistently perform physical activity. If the same patient works for an employer who provides an onsite gym, the patient could negotiate with her supervisor to utilize the gym to be physically active a few days a week.

Of the multiple additional constructs in SCT, several are worth mentioning. Albert Bandura, the author of SCT, identified self-efficacy, the confidence a person has in his or her ability to perform a behavior, as having a significant influence on behavior change.39–41 Self-efficacy has been shown to predict the amount of effort an individual will expend to learn and practice a behavior, the persistence demonstrated in the process, and the effort expended to overcome barriers.42,43 Self-efficacy is behavior specific. Therapists are familiar with the importance of self-efficacy in neurological rehabilitation as patients learn and relearn movement strategies after neurological insults and the way in which repetition, small steps, verbal persuasion, and observational learning build confidence and thus competence in the movement. These same strategies enhance self-efficacy for behavior change related to enhancing wellness, and self-efficacy is key to the development of sustainable health habits.

Goal setting and social support are two additional useful constructs in SCT that fall into the broad category of self-regulation, an important skill to develop when adopting new health behaviors.41 The setting and achievement of goals can have a profound positive impact on learning new health behaviors, like the positive role goals play in physical and occupational therapy plans of care, with the additive effect of enhancing self-efficacy when goals are both challenging and achievable. When goals are not adequately challenging, they can decrease self-efficacy. Social support involves identifying others who will provide encouragement in the form of moral support, participation in the behavior, and accountability. For certain populations, social support has been shown to be significantly related to physical and mental health, pain, coping, adjustment, and life satisfaction.44

1.3 Self-efficacy Theory

Self-efficacy theory (SET) is a subset of Bandura's (1986) social cognitive theory. According to this approach, the two key determinants of behavior are perceived self-efficacy and outcome expectancies. The latter construct refers to the perceived positive and negative consequences of performing the behavior. See Schwarzer and Fuchs (1996) for a version of this model that incorporates risk perceptions and behavioral intention, as well as components of the action phase of behavior change. No meta-analysis of SET has been published, though there is substantial evidence for the predictive validity of self-efficacy (Schwarzer and Fuchs 1996).

Causation

Several theories about the causes of intimate partner violence have been proposed over the years. Social learning theory suggests that intimate partner violence is a learned behavior. The fact that male perpetrators and female victims are more likely to report histories of exposure to violence in childhood supports this theory. However, most individuals exposed to violence in childhood do not go on to commit violence as adults, and not all abusers have violent upbringings. Furthermore, the link between poor parenting generally, including neglect, and subsequent intimate partner violence in adulthood suggests that the effect is not simply one of modeling abusive behavior. Exposure to rejecting or neglectful parenting is associated with adverse effects on intrapersonal (e.g., poor self-worth) and interpersonal development, which are associated with intimate partner violence.

A feminist perspective understands intimate partner violence against women as a form of coercive control rooted in society’s patriarchal structure, reflecting the persistent inequality in economic and social relationships between men and women. Lending support to this perspective is the finding that intimate partner violence appears to be less common in more democratic and less economically polarized societies. Although intimate partner violence occurs more often in contexts in which there is support for male authority in the family and women have less access to economic security, it is not clear why some individuals are more likely to be violent under such conditions than others.

With regard to psychological theory, there are conflicting views about the association between intimate partner violence and psychopathology. Some researchers argue that abusive males have deficits in one or more coping mechanisms, anger control, and communication skills, whereas others suggest that intimate partner violence results from dysfunctional interactional patterns between partners. Because types of intimate partner violence are not the same for all couples, there are likely multiple causes for its occurrence. Most of the research has focused on factors associated with increased risk of men abusing women (Table 228-1); however, we do not know to what extent these factors are causal from cross-sectional studies.

An explanatory framework that can guide etiologic and intervention research on intimate partner violence (and other public health problems) is the ecologic model. It attempts to integrate evidence on individual (genetic and life course), family, community, and socioeconomic structural factors. The ecologic model has recently been further developed to incorporate the impact of globalization on violence against women.6

Social cognitive theory

SCT addresses psychosocial factors and motivations influencing health behaviors and methods to promote sustained, translatable behavior change [3]. SCT is a commonly applied behavior change theory to diabetes technologies; a recent systematic review found the majority of mobile health interventions addressing diet, physical activity, or weight loss utilized SCT as the guiding framework [6]. SCT includes consideration of an individual’s prior behavior, cognitions, social environment, and physical environment when predicting future behavior. Behavior change is initiated and maintained when persons feel that they are capable of executing the desired behavior (i.e., self-efficacy) and have a reasonable expectation that the behavior will result in a desired outcome (i.e., outcome expectations). Additional SCT considerations relevant for diabetes technology include (1) an individual’s knowledge of health risks and benefits associated with target behavior, (2) identification of specific goals and strategies for tracking progress and realizing these goals, and (3) use of vicarious learning in which the observation of other people or models guides learning. Key pathways of influence include (1) tailoring content or behavioral targets to a participant’s knowledge and efficacy level, (2) monitoring progress they are making, and (3) utilizing social support to enhance learning and motivation [3].

Human Factors and Technical Considerations for Emerging Technologies

In anticipation of increased availability of OTC amplification and direct-to-consumer models of hearing health care, otolaryngologists must have an understanding of the factors, both from a design and technical perspective, that can influence an older adult's ability to use hearing technology, particularly new OTC devices currently on the market. Adequate amplification is only one aspect of addressing an older adult's hearing and communication needs. The field of human factors specializes in understanding and accounting for the unique human characteristics that influences an individual's ability to use and incorporate a piece of technology into his or her daily life.107 The primary focus is on enabling a user, an older adult, to interact with a piece of technology, an amplification device, comfortably, safely, and efficiently in an error-free manner in a dynamic environment.107 For older adults with hearing loss, the individual must learn a new technology and incorporate its use and maintenance into daily routine, while also augmenting what can be deeply entrenched communication behaviors.

Self-efficacy is an important aspect in managing any new technology, including hearing technology, and is defined as one'sperceived ability to execute a given behavior or task successfully.108 Approaches that enhance self-efficacy are associated with successful use of hearing aids among older adults.109 Bandura's Social Cognitive Theory delineates four strategies to enhance self-efficacy: performance accomplishments, vicarious experience, verbal persuasion and emotional arousal.108 These strategies may take the form of mastery experiences during device fitting and orientation through teach-backs, modeling steps or behaviors using the device, provision of immediate, specific, and positive feedback, and creating a supportive environment during training.108,110

Human characteristics, such as sensation, perception, cognition, and movement control, must be considered when designing a technology and its associated instructional materials.107 Aging affects each of these characteristics, and designs must account for these age-related changes. For example, age-related vision changes are highly prevalent. and older adults with both visual and hearing loss report lower rates of self-efficacy related to hearing aid uptake and use.109 The small buttons and batteries used in hearing aids, combined with the small font of hearing aid manuals, are often not suitable to older adults.110,111 Hearing technology can be made more suitable for older adults through the inclusion of rechargeable batteries that connect magnetically, larger buttons for volume control, and access to DVDs or online videos to supplement manuals.110 Besides accounting for changes in perception, these accommodations make devices more accessible to older adults experiencing age-related or disease-related changes in manual dexterity.107,110 Instructional materials that feature video tutorials support older adults with modeling of behaviors and reinforcement opportunities that can aid older adults experiencing changes in cognition.107,110

Social learning theory (SLT).

Bandura's social learning theory emphasizes the importance of observing and modeling the behaviors, attitudes, and emotional reactions of others.16 This theory supposes that most human behavior is learned observationally through modeling. Social learning theory explains human behavior in terms of continuous reciprocal interaction between cognitive, behavioral, and environmental influences.

Derived from SLT, social cognitive theory (SCT) is relevant to health communication primarily because it deals with cognitive and emotional events, environmental factors, and aspects of behavior as shown in Figure 10-2. It is based on the learning principles and motivational ideas of Hull, who attempted to explain behavior relative to internal states known as “drives.”17 According to SCT, behavior is a function of what one would expect to happen as reinforcement for a particular behavior. The eleven main concepts shown in Box 10-2 provide the cognitive basis for SCT. Individuals who value the outcome of a situation will attempt to learn behaviors appropriate to the situation when they believe they are capable of acceptable performance, and the performance and outcome are connected. SCT is relevant to patient education for three reasons. First, this theoretical approach brings elements of knowing, feeling, and behaving into a synergistic complex. Second, it suggests that there are varying avenues for explaining behavior. Third, it provides an opportunity to bring the fields of psychology and health behavior together in a synergistic fashion. The concepts of goal setting, skill training, and other self-care skills that are important in patient education and in a patient's adherence to a new behavior are embedded in SCT.

The Agentic Worldview of Self-Efficacy Theory

Self-efficacy theory emphasizes the importance of the individual and the individual's perceptions of his/her personal capabilities as key determinants of successful outcomes. Self-efficacy theory, and the broader social cognitive theory in which self-efficacy is encompassed, therefore clearly endorses a democratic ideal that suggests that all individuals are competent and capable of being successful, provided they have the opportunities and self-efficacy necessary to pursue their goals. Self-efficacy theory explicitly focuses on how individuals and communities can be empowered with a sense of agency that will facilitate goal attainment. This is important as self-efficacy theory does not presume that individuals who are currently successful are inherently better than those who are not as successful. Rather, self-efficacy theory would suggest that individuals who are currently struggling may not have been provided with opportunities to obtain mastery experiences or modeling necessary to develop high levels of self-efficacy. Self-efficacy theory therefore suggests that it is the responsibility of the government and society to provide everyone with sufficient opportunities to engage in mastery experiences, receive positive social persuasion, and witness positively reinforcing models that will engender a strong sense of self-efficacy.

It is worth noting, however, that self-efficacy theory does not suggest that positive self-efficacy beliefs are the only causes of important outcomes. Rather, as previously discussed, self-efficacy theory is rooted in a theory of triadic reciprocal determinism in which there is a constant interplay between personal factors (i.e., self-efficacy beliefs), behavior, and environmental factors. Self-efficacy theory emphasizes the relative importance of personal factors, but acknowledges that behavioral and environmental factors have profound effects on outcomes. This theory of triadic reciprocal determinism therefore further reinforces the idea that if the effects of the environment are consistent (i.e., an even playing field for all), then self-efficacy beliefs will take on an even greater role in determining human behavior, and ultimately shaping outcomes.

It is also important to note that self-efficacy theory does not advocate a Pollyannaish world view in which positive expectancies for the future are the sole determinant of future outcomes. There has been a recent backlash against positive thinking among many members of the popular press. Books such as Barbara Ehrenreich's Bright-Sided: How the Relentless Promotion of Positive Thinking Has Undermined America have argued that an excessive emphasis on and belief in the benefits of positive thinking has had a detrimental effect on the lives of many individuals and the society as a whole. There is much to be said about identifying the potential pitfalls of naïvely optimistic worldviews or self-help programs that suggest that positive thinking provides almost magical benefits. However, it is important for researchers, clinicians, and the public to recognize the distinction between these less scientific theories of positive thinking and empirically based theories such as self-efficacy. Self-efficacy beliefs are in no way proposed to be a panacea for all of the ills of the world nor are self-efficacy beliefs proposed to be the only psychological factor that may determine important life outcomes. Rather, self-efficacy theory proposes a more measured worldview in which opportunities to experience or witness success may promote positive evaluations of one's capacities to succeed in the future which in turn increases the likelihood of subsequent positive outcomes.

A. Social Cognitive Theory

Social cognitive theory, the cognitive formulation of social learning theory that has been best articulated by Bandura [24, 25], explains human behavior in terms of a three-way, dynamic, reciprocal model in which personal factors, environmental influences, and behavior continually interact. Social cognitive theory synthesizes concepts and processes from cognitive, behavioristic, and emotional models of behavior change, so it can be readily applied to nutritional intervention for disease prevention and management. A basic premise is that people learn not only through their own experiences, but also by observing the actions of others and the results of those actions [14]. Key constructs of social cognitive theory that are relevant to nutritional intervention include observational learning, reinforcement, self-control, and self-efficacy [7].

Principles of behavior modification, which have often been used to promote dietary change, are derived from social cognitive theory. Some elements of behavioral dietary interventions based on social cognitive theory constructs of self-control, reinforcement, and self-efficacy include goalsetting, self-monitoring and behavioral contracting [7, 15].

Self-efficacy, or a person's confidence in his or her ability to take action and to persist in that action despite obstacles or challenges, seems to be especially important for influencing health behavior and dietary change efforts [25]. Health providers can make deliberate efforts to increase patients’ self-efficacy using three types of strategies: (1) setting small, incremental, and achievable goals; (2) using formalized behavioral contracting to establish goals and specify rewards; and (3) monitoring and reinforcement, including patient self-monitoring by keeping records [14]. In group nutrition programs, it is possible to easily incorporate activities such as cooking demonstrations, problem-solving discussions, and self-monitoring that are rooted in social cognitive theory.

The key social cognitive theory construct of reciprocal determinism means that a person can be both an agent for change and a responder to change. Thus, changes in the environment, the examples of role models, and reinforcements can be used to promote healthier behavior.

Summary

Bandura's social cognitive theory of human functioning emphasizes the critical role of self-beliefs in human cognition, motivation, and behavior. Social cognitive theory gives prominence to a self-system that enables individuals to exercise a measure of control over their thoughts, feelings, and actions. In putting forth this view, Bandura reinvigorated the nearly abandoned focus on the self in the study of human processes that William James initiated nearly a century earlier. Social cognitive theory is an agentic and empowering psychological perspective in which individuals are proactive and self-regulating rather than reactive and controlled either by environmental or biological forces. Instead, the beliefs that people have about themselves are key elements in their exercise of control and of personal, cultural, and social achievement. It is because of their beliefs about their own capabilities – their self-efficacy beliefs – that people are able to exercise the self-influence required to contribute to the types of persons they become and their achievements.

Social cognitive theory

Social cognitive theory (SCT) is one of the most frequently applied theories of health behavior (Baranowski et al., 2002). SCT posits a reciprocal deterministic relationship between the individual, his or her environment, and behavior; all three elements dynamically and reciprocally interact with and upon one another to form the basis for behavior, as well as potential interventions to change behaviors (Bandura, 1977a, 1986, 2001). Social cognitive theory has often been called a bridge between behavioral and cognitive learning theories, because it focuses on the interaction between internal factors such as thinking and symbolic processing (e.g., attention, memory, motivation) and external determinants (e.g., rewards and punishments) in determining behavior.

A central tenet of social cognitive theory is the concept of self-efficacy – individuals’ belief in their capability to perform a behavior (Bandura, 1977b). Behaviors are determined by the interaction of outcome expectations (the extent to which people believe their behavior will lead to certain outcomes) and efficacy expectations (the extent to which they believe they can bring about the particular outcome) (Bandura, 1977b, 1997). For example, individuals may hold the outcome expectation that if they consistently use condoms, they will significantly reduce risk of becoming HIV-infected; however, they must also hold the efficacy expectation that they are incapable of such consistent behavioral practice. Behavior change would necessitate bringing outcome and efficacy expectations in alignment with one another. SCT emphasizes predictors of health behaviors, such as motivation and self-efficacy, perception of barriers to and benefits of behavior, perception of control over outcome, and personal sources of behavioral control (self-regulation) (Bandura, 1977a, 1977b). Another important tenet with respect to behavioral and learning is SCT's emphasis that individuals learn from one another via observation, imitation and modeling; effective models evoke trust, admiration and respect from the observer, and they do not appear to represent a level of behavior that observers are unable to visualize attaining for themselves. Thus, a change in efficacy expectations through vicarious experience may be effected by encouraging an individual to believe something akin to the following: “if she can do it, so can I”. SCT has been critiqued for being too comprehensive in its formulation, making for difficulty in operationalizing and evaluating the theory in its entirety (Munro et al., 2007). Moreover, some researchers using SCT as a theoretical basis have been criticized for using only one or two concepts from the theory to explain behavioral outcomes (Baranowski et al., 2002).